7, 2016, presents information
on how more than 3,300 Joint
Commission-accredited hospitals
performed on individual,
chart-abstracted measures of
patient care during 2015 in
comparison to previous years.

Reporting data on these
measures is a requirement of
Joint Commission-accredited
hospitals. A total of 33 measures
were described in the report, 29
of which were accountability
measures, focused on evidence-based care processes that are
closely linked to positive patient
outcomes. The measures are
relevant for accreditation,
public reporting, and pay-for-performance programs that hold
providers accountable to external
oversight entities and the public.

Measures in the report

The chart-abstracted measures
covered in the report
pertain to the following:

•Children’s asthma management
(one measure)

•Inpatient psychiatric services
(seven measures)

•Venous thromboembolism (VTE)
care (five measures)

•Stroke care (eight measures)

•Perinatal care (five measures)

•Immunization (one measure)

• Tobacco use treatment (three
measures)

•Substance use care (three
measures)

Some measures, such as
those comprising perinatal
care, show significant gains.

In 2015, the perinatal care
result was 97.6 percent—up
from 53. 2 percent in 2011,
which is an improvement
of 44. 4 percentage points.

Another is the VTE
care result, which came in
at 95. 2 percent in 2015—up
from 89. 9 percent in 2011—an
improvement of 5. 3 percentage
points. VTE medicine and/or
treatment in an intensive care
unit was 94. 5 percent in 2011

and 97.4 in 2015—a difference
of 2. 9 percentage points.

Any improvements, no
matter how large or small, are
important because they all
contribute to better care for
patients. As a result of continued
excellent performance, three
of four individual VTE care
accountability measures
were retired effective
December 31, 2015.

Meanwhile, strong reporting
performance led to the
retirement of all Surgical Care
Improvement Project (SCIP)
chart-abstracted measures in

2015. This decision was based
largely on the fact that the
composite scores were so high,
ranging in 2014 from 94. 2 percent
on the low end (appropriate
prophylactic antibiotics for
colon surgery) to 99.9 percent
on the high end (patients with
appropriate hair removal).

Pioneers in Quality recognized

This year’s annual report also
recognizes 39 Pioneers in Quality
hospitals that are at the forefront
of a new era in health care
quality reporting—one in which
hospitals collect information on
the quality of patient care through
electronic health records (EHRs)